Abstract Introduction Lymphoid interstitial pneumonia (LIP) is a lymphoproliferative interstitial lung disease characterized by lymphoplasmacytic infiltration of alveolar septae and spaces. High-resolution computed tomography commonly shows ground-glass opacities, centrilobular nodules, interstitial thickening, and frequently cysts. Definitive diagnosis requires lung biopsy demonstrating extensive septal infiltration. LIP is classically associated with autoimmune disease and HIV—more often in children and rarely in adults—with incidence decreased since widespread antiretroviral therapy (ART). Treatment centers on ART optimization, and glucocorticoids when indicated. Case Presentation A 60-year-old man with HIV, chronic obstructive pulmonary disease, opioid use disorder and bipolar disorder presented with progressive dyspnea three weeks after treatment for presumed Pneumocystis jirovecii pneumonia. Recent laboratory studies showed HIV viral load reported undetectable with CD4 count of 132 cells/µL. Initial computed tomography angiography of the chest excluded pulmonary embolism but revealed diffuse ground-glass opacities and consolidation with bronchiectatic change. Bronchoscopy with bronchoalveolar lavage (BAL) was non-diagnostic—BAL showed hemosiderin-laden macrophages and rare reactive bronchial cells. Repeat chest CT demonstrated diffuse ground-glass opacification with centrilobular emphysematous change throughout both lungs with upper-lobe predominance and lower-lobe predominant reticulation. Based on clinical and radiographic findings in setting of HIV with inconsistent anti-viral therapy, pulmonology suspected the primary etiology to be LIP. The patient was restarted on Biktarvy and initiated prednisone with mild clinical improvement. However, he subsequently developed a spontaneous left pneumothorax requiring placement of two chest tubes and intensive care unit admission. Despite high-dose corticosteroids and optimization of his antiviral medication, he developed progressive emphysematous change with persistent air leak. Following extensive goals-of-care discussions with the multidisciplinary team, he elected to transition to hospice care. Discussion This case emphasizes that spontaneous pneumothorax in suspected LIP can occur without radiographic cysts. While cyst formation is a well-recognized predisposing factor, fibrotic and emphysematous changes can increase pneumothorax risk via increased mechanical stress at pleural surfaces and shear forces during respiration (when bronchiectasis is present). Clinicians should not rely solely on cyst presence to assess pneumothorax risk; emphysematous change and subpleural fibrosis represent important alternative risk factors. In suspected LIP with fibrotic or emphysematous features, maintain a lower threshold for close monitoring, early pleural intervention planning, and multidisciplinary prognostic discussions. Management centers on ART optimization and immunosuppression. Outcomes are often poor when parenchymal fragility and persistent air leak coexist, underscoring the importance of early individualized care planning. This abstract is funded by: none
Eggett et al. (Fri,) studied this question.